Division of Hospital Medicine Emergency Contact Form

Division of Hospital Medicine Emergency Contact Form

All information provided in this form will remain confidential and will only be used in case of an emergency by the administration in our Division. If you have any questions please email Jim Nix (james.nix@ucsf.edu).

Employee Information

Employee First Name*

Employee Last Name*

Preferred Pronouns*

Employee Home Phone*

If you do not have a home phone please type "N/A."

Employee Cell Phone*

If you do not have a cell phone please type "N/A."

Employee Other Phone*

If you do not have another phone please type "N/A."

Employee Home Address*

123 Main Street, Apt. 3, San Francisco, CA 94110

Employee UCSF Email Address*

Employee Alternative Email Address*

Ex: @gmail.com, @aol.com, @yahoo.com, etc.

Employee Supervisor Name*

First and last name

Special Needs*

Ex: Allergies, etc. or please type "N/A."

Special Skills in Case of Emergency*

Ex: CPR certification, languages, etc. or please type "N/A."

Primary Emergency Contact information

Primary Contact First Name:*

Primary Contact Last Name:*

Primary Contact Relationship to Employee:*

Primary Contact Work Phone:*

If no work phone please type "N/A."

Primary Contact Personal Phone:*

Ex: Home or cell phone

Secondary Emergency Contact information

Secondary Contact First Name:*

Secondary Contact Last Name:*

Secondary Contact Relationship to Employee:*

Secondary Contact Work Phone:*

If no work phone please type "N/A."

Secondary Contact Personal Phone:*

Ex: Home or cell phone

Date Audited/Updated*

Enter today's date.

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